What would happen if the medical profession taught podiatry?

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I was doing my weekly tertiary hospital clinic today.

The new intake of specialist registrars were on board, the consultants were in action, and discussions have begun on the education program for the year.

It got me thinking about how vastly different medical education is to podiatry education (at least in the Commonwealth, I should clarify).

I thought about the compulsory registrar education rotations and interdisciplinary weekly education meetings. The role of consultants in the continuum between undergraduate, intern and postgraduate studies.

How different it seems in podiatry, especially in Australasia and the UK. An insular little profession are we.

Small podiatry departments in typically 2nd tier universities, typically unattached to any major hospital or medical school. Full time educators trying to balance research and administrative duties. The occasional guest medical practitioners coming in for lectures.

I then pondered how a bunch of interested medical practitioners would go about teaching a new undergraduate how to be a 'foot specialist'. What would they teach in the first year? How much time would they spend on the minutiae of nail and callus care. How much emphasis would they place on prescribing, surgery, general medical skills (eg history and physical examination)?

I then realised they would probably come up with something like an American DPM program.

I pondered when an 'education revolution' might come to my part of the world. It's only been about 50 years or so since American podiatry developed its DPM programs.

Then realised that I could be retired by then. So I drank some coffee, called the next patient and enjoyed the brief thrill of opening a purulent ulcer and doing an incision and drainage, saving the taxpayer a few more coins by saving a bed for the next drink driving victim...:bash:

How would you design a 'perfect' 4 year podiatry degree - what key skills would you like a podiatry graduate to have (as compared to the status quo of the past 20 to 30 years)? Which operations would you expect a graduate podiatrist to be able to do? What drugs should they be competent to prescribe/administer straight away? What types of orthotics/AFO's/applicances /prostheses? Which bits would you save for 'specialist' training? How much training would occur in hospitals, with other specialists, other professions?

Penny for your thoughts...

LL

 

Lucky, six years ago I lead the design of what I hoped would be the "perfect" three year podiatry degree for the University of Plymouth. However "perfect" means that it had to tick all the boxes with the QAA, HPC, JQAC, NHS, and University. The problem is that in order to tick all of the boxes for all of the agencies you never really achieve the perfect training programme that was in your own mind...

 

Simon

I well appreciate the reality of conflicting agenda's from differing groups that may not have the interests of having the 'best' podiatry graduates one could hope for. However, let's put that to the side and live in an alternate reality for just a moment.

What were the key 'skills' you wished your program could produce out of Plymouth?

LL

 

The 1st thing I would do is a 3 year undergrad 2 year masters program, which all 5 years must be completed to call yourself a podiatrist.

 

In what ways do you feel that this might be better than, say, a 4 year graduate 'DPM' style course?

What skills would you expect a podiatrist like this to have?

Should graduates be capable of;

• lesser toe surgery
  administering corticosteroid injections
  comprehensive wound care (eg vacuum assisted closure, total contact casts)
  prescribing narcotic analgesia and parenteral antibiotics
  ordering all appropriate radiology and lab studies
  

I say this in the context of Australian 4 year graduate medical degrees...

LL

 

It would allow the basic Podiatry course to continue but then allow a more specialist 2 years. Pods that want to specialise in surg would complete a program geared to completeing their Dr in Podiatric Surg, or a Biomechancis type pod would then complete mechanics and research at a much higher level than currently seen today. This would not mean the death of the General Pod. They would complete courses from each of the main sub groups to make up a certain amount of points.

Also by making the course longer Practical session´s would not be reduced for more theory, also it would reduce the student who completes the course an drops out of the profession after working 3-5 years I beleive.

It would also allow more Job training in the field by people who work in the field. Ie working 1-2 days as week a Pod surg assisstant or a Podiatric assisstant in Private practice.

Your list certainly seems a good place to start and skills that I would have liked to be taught when I was at School.

 

It is always tempting to want to add more to get "better" graduates. However I would observe in passing that this can itself be a two edged sword.

One of the things about podiatry which IMO lends to the internal division is the sheer scope of practice. We have on one hand pods who work in the NHS and IPP doing the coalface work, the regular, routine and essential palliative care of pathological feet. In the other we have people working in acute settings in hospitals and in MSK settings doing work which to the casual observer, would seem completely different!

I will note now in passing before somebody jumps down my throat that I feel these are BOTH essential aspects of podiatry and deserve parity of esteem.

One of the frustrations I have found, in employing new graduates, is that many expect to be doing the latter type of work from the get go and consider themselves "above" the former. I would also note that many lack some fundamental skills in the palliative sphere!

If we keep adding to the undergraduate syllabus, we may increase this tendancy.

However I do wholeheartedly agree with LL in the sense of how Podiatry is taught. The idea of having students "in the deep end" in the real world is one I think would improve the quality of education and drastically increase the amount of experience they have prior to qualification. We have people "on placement" for 4 weeks of their final 2 years. Physiotherapy, I know, has far far more placement.

Whilst I think the "teaching clinics" we see at the universities are an essential and ideal place to start one's training, I think that by the end of it students should be more familier with the real world. When I qualified I went from an environment in which I saw 6 patients a day, often with another student and with backup if I ran late to being on my own seeing 24 patients a day with precious little or no support. That is a culture shock many are just not prepared for!

Regards
Robert

 

Robert

I appreciate the, albeit necessary, defence of general care podiatry.

Like the (often silent) majority of practitioners, I too spend more than enough time on this aspect of our work. It is a 'skill' that is honed through much practice and repetition. Still one of the great joys of my work it to carefully excise a painful corn with little discomfort and let a patient get about their day in instant comfort.

Yet, I feel a comparison with dentistry is wanting.

Much 'routine' care dentistry is passed on to 'dental hygienists' these days. The dentist now spends more of their time on more involved procedures ,delegating these tasks to others.

At some point in time, sooner of later, podiatry needs to dip its toe deeper into the waters of this issue.

Having spent many years in operating theatres and around podiatric surgery, I have come to view the world differently to those who stay away from such things. I almost of the view that any repetitive task can be taught to almost anyone. The difference between adequate and optimal results is often simply a case of experience, and appreciation of the 'art'. No doubt the same can be said of orthotic therapy, of which we spend an almost inappropriate amount of time discussing here.

From an educational standpoint, I feel far too much time is spent on the issue of trying to gain expertise in general podiatry care in the formative years of podiatry education. It is a relatively simple process to teach someone how to enucleate a corn, debride hyperkeratosis or reduce a gryphotic nail. Many years of practice makes one far more efficient and productive at doing the same - this just needs to be accepted, rather than perpetuate the expectation that much practice must be done in this area whilst an undergraduate.

I know many GPs who occasionally dabble in such things, without ever being trained how to do so. By and large they are generally very average in their abilities to do so, but this appears (even superficially) to be quite reasonable from a public health perspective.

I had to ask a registrar today for a Rx for flucloxacillin 250mg qid for a diabetic foot infection. The first thing she did was bring up her online prescribing software to check what dosage to write for, just in case I was incorrect. One might have an expectation that she would 'know' this aspect of her job already - but she will still not confident in her prescribing abilities as yet - despite being a medical graduate of some years standing.

What strikes me as more important, given ageing populations, health workforce shortages and the like, is the desperate need to bring Commonwealth podiatry education to a far more productive standard. Urgently.

We need to be more useful in the system, and not in small pockets of specialist activity.

It is never too late to start planning for the next generation. We need to start changing course.

LL

 

I agree with your visions LL, we need to become more fully integrated into the health system even if it means doing a residency year after graduation. This will give us more exposure, acceptance and respect with other health care professionals. I think the US DPM approach is pretty much the gold standard and has moved the profession forward tremendously in the US. We really need to start thinking of a similar version to incorporate throughout the Commonwealth. I am sure this would attract more quality students who would be interested in moving the profession forward. As the medical profession moves forward, we need to as well.

Harry

 

Hi

I tend to disagree with the notion that the DPM approach is the gold standard for Podiatry Education.

I do agree with the point regarding the advancement of the profession within the medical profession in the US, however I tend to believe that this has primarily been in the surgical sphere. A 6 week rotation through some of the states in the US generally showed me a great deal of surgical and anatomical understanding, however I personally believe that as podiatrists we can offer more than surgical interventions.

I am an advocate for the advancement of Podiatric Surgeons in Australia, and in those cases where surgery is indicated, that is to whom I refer. However I believe our primary aim as podiatrists is to keep people out of the theatre as this is where we provide the greatest value in keeping medical costs down (and I acknowledge that at a surgical level, our Podiatric Surgeons are better and far more cost effective than Orthopaedic Surgeons). I do believe that our case is being made with regard to integrating the profession into the main medical paradigm. An example of this is the introduction of Medicare rebates for primary care interventions including podiatry.

If I think about what a podiatry undergraduate should be capable of at completion I believe strong general skills, sound knowledge of biomechanics (the basic theories and principles and how to use these to achieve the best outcomes for their patients) and how this affects orthotic prescription, basic nail and sharps procedures (Winograds, Digital Arthroplasty, Exostectomy), and an understanding of drug affects and interactions pertaining to antibiotic, antifungal, pain management and corticosteroid therapy.

I believe a surgical speciality should be there for more involved surgical interventions such as bunion, digital straightenings (using K-wires etc) and the more complex procedures, and the model that the ACPS has formulated has significant merit. I wouldn't have an issue with the surgical specialty including the procedures mentioned in the paragraph above.

Having said all that I believe that it is unrealistic to have anybody leave a tertiary institution as a Podiatrist capable of working unsupervised. There needs to be some form of internship, fellowship, mentoring type system in place. I also believe there needs to be some form of benchmarking across the profession to maintain professional standards and competencies.

LL does this warrant a penny??